25例胰岛素治疗患者酗酒后致严重低血糖的因为分析与护理

分析总结25例糖尿病胰岛素治疗患者酗酒后致严重低血糖的原因及护理对策。空腹酗酒、酗酒后酒精使胰岛素分泌及作用增强、酗酒后肝功能损害、老年糖尿病患者是酗酒导致严重低血糖的原因。认为迅速判断、紧急处理以防止低血糖所致脑功能进一步损害，是成功抢救酗酒致胰岛素治疗患者严重低血糖反应的关键。针对酗酒致低血糖原因，适时进行个体化低血糖防范知识教育，帮助患者认识酗酒导致严重低血糖的危害；根据病情、生活方式等指导患者配合积极戒酒或为其制定个体化饮酒方案；积极随访，控制诱因；强化自我管理知识和技能，指导患者家属积极监督，促使患者行为改变，避免酗酒行为复萌，可以预防严重低血糖事件再次发生。本组25例胰岛素治疗患者酗酒后致严重低血糖反应病例中，24例抢救成功，未遗留各种脑功能障碍后遗症及诱发心脑血管事件，血糖控制平稳出院，随访1～3年，均无严重低血糖事件再次发生。     

老年危重Ⅱ型糖尿病患者的强化胰岛素治疗

【目的】探求适应危重老年Ⅱ型糖尿病患者的胰岛素治疗方案。【方法】应用强化胰岛素治疗危重Ⅱ型老年糖尿病患者29 例。【结果】患者的糖化血红蛋白从(17 .1 ±9) % 降至(7 .3 ±2 .6) % ,并随着血糖控制至接近正常水平,患者的一般情况及心肾功能均有改善,肺部及泌尿道感染减少、微血管并发症减轻,病情稳定后患者未发生过严重低血糖。【结论】强化胰岛素治疗较常规胰岛素治疗能显著改善患者的血糖水平。     

Pitfalls in Diagnosing Hypoglycemia Due to Exogenous Insulin: Validation and Utility of an Insulin Analog Assay

ObjectiveTo overcome the limitations of commercially available insulin immunoassays which have variable detection of analog insulin and can lead to clinically discordant results and misdiagnosis in the workup of factitious hypoglycemia.Patients and MethodsWe performed analytical validation of a liquid chromatography high resolution accurate mass (LC-HRAM) immunoassay to detect insulin analogs. We completed clinical assessment using a large cohort of human serum samples from 78 unique individuals, and subsequently used the assay in the evaluation of eight individuals with high diagnostic suspicion for factitious hypoglycemia.ResultsThe performance characteristics show that the LC-HRAM immunoassay can be applied to detect five commonly used synthetic insulin analogs (lispro, glulisine, aspart, glargine metabolite, and detemir) in human serum. Our clinical cases show that this assay could be used in the diagnosis of factitious hypoglycemia by identifying the analog insulin(s) in question.ConclusionThe LC-HRAM immunoassay reported here overcomes a gap in our diagnostic pathway for hypoglycemia. The results obtained from our studies suggest that this method is appropriate for use in clinical laboratories when factitious hypoglycemia is considered as a differential diagnosis.     

Emergency medicine: Where to from here? The College

This paper describes two group presentations of intoxicated patients to the Emergency Department of Gold Coast Hospital in October 1996 and July 1997 respectively. A total of 14 patients received treatment. The clinical features, investigation findings and clinical course of each patient are outlined. A discussion is undertaken of the literature surrounding the emergence of gamma hydroxybutyrate (GHB) as a drug of abuse, and of the major issues involved in the emergency department management of such patients.     

Ketorolac TVomethamine Use in a University-based Emergency Department

Objective: To assess the use of parenteral ketorolac tromethamine (KT) in the emergency department (ED).
Methods: During a six-month period, KT was administered in an uncontrolled, nonblinded fashion to a series of ED patients experiencing acute pain. The patients rated pain on a previously validated visual analog pain scale before receiving KT. They repeated this procedure one hour after KT administration, prior to additional analgesia, or preceding release, whichever came first. Analgesic response was assessed by comparing pretreatment and posttreatment pain scores for the entire study population by the Wilcoxon rank sum test. Possible effects of specific variables (patient age, gender, race, indication for KT, route, dose, previous use of NSAIDs, and concurrent administration of muscle relax-ants) were assessed using the Kruskal-Wallis test.
Results: Of the 445 patients enrolled, 375 (84%) reported pain relief with KT, only seven (2%) worsened, and the remainder (14%) reported no change. Overall pain reduction was 37.6 ± 27.2 (SD) mm (100-mm scale) for the entire study population. The pain scores obtained after KT administration were significantly lower than those obtained prior to KT administration (p < 0.001). The only variable that significantly influenced pain score reduction was indication for KT (p = 0.0001). Nephro-lithiasis and toothache patients had the largest mean reductions in pain. No significant side effect was reported.
Conclusion: Parenteral KT is a useful and safe analgesic for ED patients. The agent generally provides analgesia and is particularly promising for patients with nephrolithiasis or toothache.     

Community–wide Emergency Department Visits by Patients Suspected of Drug–seeking Behavior

Objective: To measure community–wide ED use by patients at high risk for drug–seeking behavior.
Methods: A retrospective, observational study was performed to analyze a cohort of university hospital ED patients seen January 1 to June 30, 1990, for specific pain–related diagnoses (i.e., ureteral colic, toothache, back pain, abdominal pain, or headache) and either independently identified on at least one other local hospital's "patient alert" list or having a drug–related death during 1990. Patients with terminal illnesses were excluded. The frequency of ED (and affiliated urgent care clinic) visits and hospital admissions were determined for January 1 to December 31, 1990, at seven local hospitals. Detailed, supplemental chart review was performed for visits to three of these hospitals from 1990 to 1992.
Results: Thirty patients were identified as being at risk for drug–seeking behavior (mean age: 34.3 years; range: 21–55 years; 50% males). We identified 379 visits for this cohort (86% ED visits, 9.8% urgent care visits, 4.7% hospital admissions), for an average of 12.6 visits (range: 2–33) per patient per year. On average, each patient visited 4.1 (range: 1–7) different hospitals and used 2.2 (range: 1–6) different aliases. Two patients died of drug overdose. Supplemental chart review revealed 28 episodes (among 17 different patients) in which a patient was told that he or she "would receive no further 'narcotics'" from that facility; these patients subsequently received controlled substances from another hospital in 93% of these instances and from the same facility in 71%.
Conclusions: Patients identified as being at high risk for drug–seeking behavior have high community–wide ED visit rates. Improving communication between and within hospitals may help identify patients who could benefit from more consistent community–wide care and appropriate treatment for addiction.     

Distances to Emergency Department and to Primary Care Provider's Office Affect Emergency Department Use in Children

Objectives:  Patients of all ages use emergency departments (EDs) for primary care. Several studies have evaluated patient and system characteristics that influence pediatric ED use. However, the issue of proximity as a predictor of ED use has not been well studied. The authors sought to determine whether ED use by pediatric Medicaid enrollees was associated with the distance to their primary care providers (PCPs), distance to the nearest ED, and distance to the nearest children's hospital.
Methods:  This historical cohort study included 26,038 children age 18 and under, assigned to 332 primary care practices affiliated with a Medicaid health maintenance organization (HMO). Predictor variables were distance from the child's home to his or her PCP site, distance from home to the nearest ED, and distance from home to the nearest children's hospital. The outcome variable was each child's ED use. A negative binomial model was used to determine the association between distance variables and ED use, adjusted for age, sex, and race, plus medical and primary care site characteristics previously found to influence ED use. Distance variables were divided into quartiles to test for nonlinear associations.
Results:  On average, children made 0.31 ED visits/person/year. In the multivariable model, children living greater than 1.19 miles from the nearest ED had 11% lower ED use than those living within 0.5 miles of the nearest ED (risk ratio [RR] = 0.89, 95% CI = 0.81 to 0.99). Children living between 1.54 and 3.13 miles from their PCPs had 13% greater ED use (RR = 1.13, 95% CI = 1.03 to 1.24) than those who lived within 0.7 miles of their PCP.
Conclusions:  Geographical variables play a significant role in ED utilization in children, confirming the importance of system-level determinants of ED use and creating the opportunity for interventions to reduce geographical barriers to primary care.     

Effects of Burn Injury on Insulin Secretion and on Sensitivity to Insulin in the Rat in vivo

Abstract. Both insulin resistance and impairment of insulin secretion are know to occur in man after injury. The relative importance of these effects was studied in rats 2 h after a non-lethal 20 % dorsal scald. No impairment of insulin secretion was found after this injury. Concentrations of both blood glucose and plasma insulin were elevated in scalded rats. Scalded rats responded to intravenous glucose injection (1. 0 g/kg) with a further rise in plasma insulin concentration, which remained normal for the prevailing blood glucose concentration. However, marked impairment of glucose tolerance was observed, indicating the presence of insulin resistance. After intravenous insulin injection (1. 0 U/kg) the initial rate coefficient for fall of blood glucose concentration was significantly lower (p < 0–02) in scalded (mean 3. 9 % min. ^-1) than in control rats (mean 6–3 % min. ^-1). The minimum in blood glucose concentration after insulin injection was reached at 10 min. in control rats, but not until 60 min. after injection in scalded rats. This difference was due to a delay in compensation for the hypoglycaemia in the scalded rats, since the rate of disappearance of insulin measured by injection of a tracer of 25i-labelled bovine insulin was not decreased after this injury. It was concluded that the impairment of glucose utilization in scalded rats (Heath and Corney, 1973) is due to decreased sensitivity to insulin rather than to suppression of insulin release.     

Marijuana Use and Prior Injury among Injured Problem Drinkers

OBJECTIVES: The purpose of this paper is to better understand marijuana use among injured problem drinkers in the emergency department (ED). The specific objectives are: 1) to assess the prevalence of marijuana use; 2) to identify factors associated with marijuana use; 3) to determine whether prior injury is associated with marijuana use; and 4) to determine whether marijuana-using problem drinkers want to change behaviors. METHODS: The authors conducted a post-hoc analysis on data obtained prospectively. Subjects had injury and problem drinking: either measurable alcohol level (blood alcohol concentration, BAC), report of drinking, or an Alcohol Use Disorders Identification Test (AUDIT) score of > or =8. The study was conducted on weekend nights; 3,776 injured ED patients were screened, 383 refused, 578 were enrolled, and 433 had complete data. RESULTS: Of the 433 subjects, 48.3% reported using marijuana in the three months prior. Marijuana-using problem drinkers had more hazardous drinking, higher AUDIT scores (14.0 vs. 11.4, p < 0.001), and higher risk-taking scores (12.4 vs. 10.1, p < 0.001). More used other drugs (69.7% vs. 30.3%, p < 0.001). In regression analyses, marijuana use remained an independent predictor of prior injury (OR = 2.16, 95% CI = 1.25 to 3.75), particularly prior alcohol-related (OR = 2.26, 95% CI = 1.45 to 3.53) and motor-vehicle-related (OR = 1.69, 95% CI = 1.03 to 2.79) injury. Readiness-to-change scores were similar (4.14 vs. 4.22, p = 0.21) between users and nonusers. CONCLUSIONS: Marijuana use among injured problem drinkers is prevalent. Their risk of prior injury is increased. Counseling for alcohol and injury should address marijuana use.     

A Survey of Bedside Ultrasound Use by Emergency Physicians in California

Objective. The purpose of this study was to investigate the current practice of emergency physician–performed bedside ultrasound examinations in California and to assess differences between academic and community practice. Methods. We queried all emergency departments (EDs) in California to determine whether bedside ultrasound was used by emergency physicians. Among EDs that were using bedside ultrasound, we administered a survey to assess use patterns, credentialing criteria, and quality assurance (QA) programs. Results. We contacted all eligible EDs (n = 293) by telephone and had a 100% response rate for our primary question: 101 EDs (34%) reported use of bedside ultrasound. Of these 101 EDs, 97 (96%) responded to the secondary survey, showing the following: (1) 48% of physicians at each site were credentialed to use ultrasound in at least 1 modality; (2) 70% of EDs used American College of Emergency Physicians (ACEP) criteria for credentialing guidelines; and (3) 33% had an ultrasound QA program. Comparing practice settings, 68% of academic departments used bedside ultrasound compared with 29% of community departments (difference, 39%; 95% confidence interval [CI], 23% to 54%; P < .0001). In academic departments, a mean of 60% of physicians were credentialed, compared with 41% in community EDs (difference, 19%; 95% CI, 2.5% to 35%; P = .036). Conclusions. Most California EDs do not use bedside ultrasound. Although most EDs using ultrasound report that they follow ACEP emergency ultrasound guidelines, most do not have a QA program as recommended by these guidelines. Compared with community EDs, academic EDs are more likely to use bedside ultrasound, have physicians credentialed in ultrasound use, and have QA programs.     

Ecstasy‐induced acute coronary syndrome: Something to rave about

Ecstasy or 3,4‐methylenedioxymethamphetamine is a commonly used illicit recreational drug, enjoying popularity for its stimulant effects. Although acute coronary syndrome is recognized after cocaine and methamphetamine use, association with Ecstasy use has rarely been reported. We report three cases of significantly delayed acute coronary syndrome and ST elevation myocardial infarction related to ingestion of Ecstasy.     

Alcohol as a Factor in 911 Calls in Denver

Background: Excessive alcohol consumption is associated with a substantial number of emergency department visits annually and is responsible for a significant number of lives lost each year in the United States. However, a minimal amount is known about the impact of alcohol on the EMS system. Objectives: The primary objective was to determine the proportion of 9-1-1 calls in Denver, Colorado in which (1) alcohol was a contributing factor or (2) the individual receiving EMS services had recently ingested alcohol. The secondary objectives were to compare the characteristics of EMS calls and to estimate the associated costs. Methods: This was a prospective observational cohort study of EMS calls for adults from July 1, 2012, to June 30, 2014. Primary outcomes for the study were alcohol as a contributing factor to the EMS call and recent alcohol consumption by the patient receiving EMS services. Logistic regression was utilized to determine the associations between EMS call characteristics and the outcomes. Cost was estimated using historic data. Results: During the study period, 169,642 EMS calls were completed by the Denver Health Paramedic Division. Of these 71% were medical and 29% were trauma-related. The median age was 45 (interquartile range [IQR] 29–59) years, and 55% were male. 50,383 calls (30%) had alcohol consumption, and 49,165 (29%) had alcohol as a contributing factor. Alcohol related calls were associated with male sex, traumatic injuries including head trauma, emergent response, use of airway adjuncts, cardiac monitoring, glucose measurement, use of restraints, use of spinal precautions, and administration of medications for sedation. Estimated costs to the EMS system due to alcohol intoxication exceeded $14 million dollars over the study period and required in excess of 37 thousand hours of paramedic time. Conclusions: Compared to 9-1-1 calls that do not involve alcohol, alcohol-related calls are more likely to involve male patients, emergent response, traumatic injuries, advanced monitoring, airway adjuncts, and medications for sedation. This represents a significant burden on the emergency system and society. Further studies are needed to evaluate whether additional interventions such as social services could be used to lessen this burden.     

Use and abuse of analgesics in tension-type headache

Eighty patients suffering from tension-type headache for an average of 21 years were asked to report on all drugs they had ever taken (type, dosage, duration of intake, efficacy) or were taking currently. The patients had consumed on average 6.3 different drugs. The cumulative doses of derivatives of para-aminophenol, pyrazolone, and salicylic acid in some cases reached a maximum of several kilograms. Most drugs were classified by the patients as "moderately effective". The rating "very effective" was assigned primarily to barbiturates; however, barbiturates are no longer used as components of compound analgesic drugs in Austria. At the time of investigation, patients consumed 2.5 (mean) different drugs, primarily as compound preparations. Seventeen patients (21%) showed signs of possible analgesics- or ergotamine-induced headache and were therefore advised to undergo withdrawal therapy. Our results show that patients with tension-type headache are at considerable risk of becoming drug-dependent and of acquiring analgesics-induced headache.     

A Survey of Emergency Physicians Regarding Due Process,Financial Pressures,and the Ability to Advocate for Patients

Background

A 1998 survey of emergency physicians indicated that many were threatened with adverse actions when advocating regarding the quality of care or raising concerns about financial issues.

Study Objectives

To assess the current state of these issues.

Methods

An anonymous electronic survey of emergency physicians was conducted using the American Medical Association’s database.

Results

Of the 1035 emergency physicians who received the survey, 389 (37.6%) answered the questions. Over half had been in practice for 16 or more years and 86% were board certified. Of those who knew the answer to the question, 62% (197 of 317) reported that their employer could terminate them without full due process and 76% (216 of 284) reported that the hospital administration could order their removal from the clinical schedule. Nearly 20% reported a possible or real threat to their employment if they raised quality-of-care concerns. Financial pressures related to admission, discharge, and transfer of patients were also noted by a number of respondents. Physicians who worked for contract management companies reported a higher incidence of impaired practice rights.

Conclusion

Practicing emergency physicians continue to report substantial concerns regarding their ability to speak up about the quality of care and pressure regarding financial matters related to patient care.     

Psychosocial Difficulties and Emergency Department Use

Objective: To determine whether psychosocial difficulties are more prevalent among ambulatory patients using the ED for nonemergent complaints as compared with ambulatory patients having emergent complaints.
Methods: A survey of noncritical ED patients was performed using anonymous questionnaires addressing psychosocial difficulties: psychiatric illness, educational level, homelessness, alcohol and/or drug dependency (CAGE and DAST surveys), and depression (DSM-III criteria). Three independent physicians ranked each patient's chief complaint as either emergent or appropriate for primary care. The majority ranking was used to determine whether the complaint was emergent. Groups with and without specific psychosocial difficulties were compared for their proportion of emergent vs primary care complaints.
Results: Of 700 patients, 367 (52%) met criteria for ≥1 psychosocial difficulty [acute psychosis—36 (5%), illiteracy—139 (20%), homelessness—45 (6%), alcohol dependency—111 (16%), drug dependency—66 (9%), and depression—130 (19%)]. There were 379 (54%) ED visits considered emergent. Patient groups with vs without ≥ psychosocial difficulty had similar rates of emergent visits (58% vs 50%, p = 0.04). Emergent visit rates also were similar for subgroups with vs without specific psychosocial difficulties: psychosis (56% vs 54%, p = 1.00), illiteracy (58% vs 53%, p = 0.89), homelessness (62% vs 54%, p = 0.33), alcohol dependency (62% vs 53%, p = 0.08), drug dependency (59% vs 54%, p = 0.47), or depression (58% vs 53%, p = 0.42).
Conclusion: Psychosocial difficulties are common among ED patients; however, emergent complaints are just as common in these patients as they are in those without psychosocial difficulties.     

Amphetamine Abuse in Emergency Department Patients Undergoing Psychiatric Evaluation

Background

Amphetamine abuse accounts for numerous Emergency Department (ED) visits and is often associated with psychiatric disease, with many patients requiring involuntary psychiatric hold placement. It is a common practice in EDs to obtain a urine drug screen (UDS) as part of the “medical clearance” process for psychiatric patients. However, the prevalence of amphetamine-positive UDS in ED patients with psychiatric disease is unknown, as is the relationship of the UDS test to the final patient disposition.

Objectives

The objectives of this study were to determine the prevalence of amphetamine-positive UDS in ED patients undergoing psychiatric evaluation, and whether amphetamine-positive UDS is associated with involuntary psychiatric hold placement.

Methods

This was a retrospective study of adult patients seen in a single urban university ED who had a psychiatric evaluation and a UDS over a 1-year period. Eligible patients had results of the UDS, placement of involuntary holds, past psychiatric history, chief complaint, insurance status, and demographic information recorded. Regression analysis was performed, adjusting for the listed covariates, to evaluate the independent association of amphetamine-positive UDS and involuntary psychiatric hold placement.

Results

A total of 1207 patients were included for analysis. Amphetamine-positive UDS were found in 14.8% of patients. Multivariate analysis showed no association of a psychiatric hold due to presence of amphetamines on UDS (adjusted odds ratio [OR] 0.76, 95% confidence interval [CI] 0.55–1.05, p = 0.1). The only significant factor in placement of an involuntary hold was a past psychiatric history (adjusted OR 1.8, 95% CI 1.2–2.7, p = 0.005).

Conclusions

The prevalence of amphetamine-positive UDS was high in the study population; however, there was no independent association of amphetamine-positive UDS with involuntary psychiatric hospitalization.     

The Use of Health Care Policy to Facilitate Evidence-based Knowledge Translation in Emergency Medicine

Health care policy can facilitate emergency medicine knowledge translation (KT). Because of this, the 2007 Academic Emergency Medicine Consensus Conference on KT identified a specific theme regarding issues of health care policy and KT. Six months before the Consensus Conference, international experts in the area were invited to communicate on health care policies regarding all areas of KT via e-mail and "Google groups." From this communication, and using available evidence, specific recommendations and research questions were developed. At the Consensus Conference, additional comments were incorporated. This report summarizes the results of this collaborative effort and provides a set of recommendations and accompanying research questions to guide development, implementation, and evaluation of health care policies intended to promote KT in emergency medicine. The recommendations are to 1a) involve appropriate stakeholders in the health care policy process; 1b) collaborate with policy makers when health care policy focus areas are being developed; 2) use previously validated clinical practice guideline development tools; 3) address implementation issues during the development of health care policies; 4) monitor outcomes with performance measures appropriate to different practice environments; and 5) plan periodic reviews to uncover new clinical evidence, new methods to improve KT, and new technologies. To advance the further development of these recommendations, a research agenda is proposed.     

Review article: Workplace violence in the emergency department: A systematic review and meta analysis

Patient or visitor perpetrated workplace violence (WPV) has been reported to be a common occurrence within the ED. No universal definition of violence or recording of such events exists. In addition ED staff are often reluctant to report violent incidents. The true incidence of WPV is therefore unclear. This systematic review aimed to quantify WPV in EDs. The association of WPV to drug and alcohol exposure was explored. The databases MEDLINE, Embase, PsycInfo and the Cochrane Library were searched from their commencement to 10 March 2016. MeSH terms and text words for ED, violence and aggression were combined. A meta‐analysis was conducted on the primary outcome variable‐proportion of violent patients among total ED presentations. A secondary meta‐analysis used studies reporting on proportion of drug and alcohol affected patients occurring within the violent population. The search yielded a total of 8720 records. A total of 7235 were unique and underwent abstract screening. A total of 22 studies were deemed relevant according to inclusion and exclusion criteria. Retrospective study design predominated, analysing mainly security records and incident reports. The rates of violence from individual studies ranged from 1 incident to 172 incidents per 10 000 presentations. The pooled incidence suggests there are 36 violent patients for every 10 000 presentations to the ED (95% confidence interval 0.0030–0.0043). WPV in the ED was commonly reported. There is wide heterogeneity across the study methodology, definitions and rates. More standardised recording and reporting may inform preventive measures and highlight effective management strategies.